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A 36-year-old previously fit green-keeper at a golf course was admitted to the infectious diseases unit with a 5-week history of puffy hands, weakness of the arms and legs, and fatigue. He was finding it difficult to stand from sitting and had episodes of night-time fever. There was no travel history. He owned a dog. There was no history of tick bites, no contact with other individuals with a similar history, no past medical history, and no relevant family history. He had been a smoker of 15 cigarettes a day since age 19 years. Specific enquiry excluded Raynaud’s syndrome, dryness of eyes or...

A 36-year-old previously fit green-keeper at a golf course was admitted to the infectious diseases unit with a 5-week history of puffy hands, weakness of the arms and legs, and fatigue. He was finding it difficult to stand from sitting and had episodes of night-time fever. There was no travel history. He owned a dog. There was no history of tick bites, no contact with other individuals with a similar history, no past medical history, and no relevant family history. He had been a smoker of 15 cigarettes a day since age 19 years. Specific enquiry excluded Raynaud’s syndrome, dryness of eyes or mouth, rashes, or difficulty in swallowing and there was no change in bowel habit.